What is a reasonable next blood pressure medication for a patient with tobacco use disorder, peripheral vascular disease (PVD), prediabetes, hypertension (HTN) with a goal blood pressure below 130/80, aortoiliac obstruction, and abdominal aortic aneurysm (AAA) who is currently on amlodipine (Norvasc) for blood pressure control?

Angiotensin Receptor Blocker (ARB) is the Most Appropriate Next Blood Pressure Medication

An ARB such as losartan should be added as the next antihypertensive medication for this patient with tobacco use disorder, PVD, prediabetes, HTN, aortoiliac obstruction, and AAA who is currently on amlodipine. 1, 2, 3

Rationale for ARB Selection

ARBs are particularly indicated for this patient for several reasons:

1. Comorbidity-Specific Benefits:

   • ARBs are recommended first-line for patients with vascular disease 2
   • Losartan specifically has demonstrated benefits in reducing stroke risk in hypertensive patients 3
   • ARBs provide renal protection, important for a patient with prediabetes who is at risk for developing diabetic nephropathy 2, 3

2. Complementary Mechanism:

   • The patient is already on amlodipine (a dihydropyridine calcium channel blocker)
   • Adding an ARB provides synergistic blood pressure lowering by targeting a different pathway 2
   • This combination is supported by the International Society of Hypertension guidelines for non-Black patients 1

3. Target Organ Protection:

   • ARBs provide vascular protection beyond BP reduction, critical for a patient with PVD and AAA 2
   • Losartan has shown specific benefits in reducing cardiovascular events compared to other antihypertensives 3

Medication Details

• Starting Dose: Losartan 50 mg once daily
• Titration: Can be increased to 100 mg daily if needed
• Monitoring: Follow up within 2-4 weeks to assess BP response and adjust dosage if needed

Alternative Options (If ARB Contraindicated)

If ARBs are contraindicated or not tolerated:

1. ACE Inhibitor: Would be equally appropriate for this patient's comorbidities but has higher risk of cough and angioedema 2

2. Thiazide-like Diuretic: Could be considered as a third agent if BP remains uncontrolled on ARB + CCB combination 1, 2

Important Considerations

• Smoking Cessation: Critical to address the patient's tobacco use disorder as smoking significantly worsens vascular disease outcomes 4, 5

• BP Target: Aim for <130/80 mmHg given the patient's high cardiovascular risk profile 1, 2

• Medication Adherence: Ensure patient understands the importance of consistent medication use and follow-up

• Lifestyle Modifications: Emphasize sodium restriction, DASH diet, regular exercise, and weight management as essential components of treatment 2

Monitoring Plan

• Check BP, renal function, and electrolytes within 2-4 weeks of starting the ARB
• Assess for side effects including dizziness, which is the most commonly reported adverse effect 6
• Continue home BP monitoring to guide treatment adjustments
• Consider comprehensive vascular risk management including statin therapy given the patient's multiple vascular risk factors 2